Necrosis

“ By the term necrosis we mean mortification, or the state of a bone when it is deprived of life. Dunglison says: "This condition is to the bone what gangrene is to the soft parts." It is popularly known as fever-sore, there being no distinction made between this species of sore and those ulcers which affect only the soft tissues of the body. When [pg 457] any part of a bone becomes necrosed, it is treated as a foreign body. Nature makes an effort for its removal, and at the same time attempts to replace it with new and healthy materials. ”

“ In adults necrosis is rare excepting as a localized patch usually situated superficially in the cortex of the mastoid process. Partial necrosis of the labyrinth, more especially of the vestibule and the portions of the semicircular canals, is also met with occasionally. When the necrosed area is superficial, such as the squamous portion of the temporal bone or the cortex of the mastoid process, it should be removed. If, however, it be situated more deeply, forcible removal should not be attempted until the sequestrum becomes loose, the wound cavity being meanwhile kept as aseptic as possible. ”

“ When the necrosed portion of bone is small, and is free from infective properties, it is quite possible that it may, as is the case with small spots of necrosis in softer tissues, be removed by a process of absorption. ”

“ Contraction there causes an extensive destruction of delicate cells, and, by cutting off the blood supply, a great impairment of function, if not actual necrosis, of an infinite number of cells which were not directly affected by the preceding inflammation. ”

“ Under this division we shall consider the following conditions, all of which are characterized by an alteration in the quality and an impairment of function in the affected tissue: 1. Anæmic necrosis; 2. Parenchymatous degeneration; 3. Fatty changes, infiltration and degeneration; 4. Brown atrophy; 5. Amyloid degeneration; 6. Hyaline degeneration; and 7. Calcareous degeneration.
[p. 610] 1. Anæmic necrosis is a condition which results in the heart-muscle when a branch of the coronary artery is blocked either by a thrombus or an embolus, or is obliterated by a progressive sclerosis. ”

“ Necrosis.—Death of tissue may follow an injection of paraffin when too much pressure has been applied, or when too much has been injected into the tissue, cutting off the blood supply, or when the injection has been made into the skin instead of beneath it. Again, constitutional disease, such as diabetes or Bright’s disease, may superinduce the breaking down of the tissue. ”

“ If, however, the reaction induced by the infection is insufficient to check the growth and spread of the organisms, or to inhibit their toxin production, local necrosis of tissue may take place, either in the form of suppuration or of gangrene, or the toxins absorbed into the circulation may produce blood-poisoning, which may even prove fatal. ”

“ Necrosis may also be due to the bruising of the tissues by large hailstones, to gun-shot wounds, or to any form of contusion which kills the living cells of cortex and cambium.
Necrosis is a natural and common result of fire, and it frequently happens after forest-fires which have run rapidly through the dry underwood, fanned by steady winds, that the lower parts of the boles are scorched on one side only. The killed cambium and cortex then dry up in black necrotic patches, which may eventually heal up by intrusion of callus from the uninjured parts. ”

“ Thrombi in the afferent and efferent vessels contribute to the necrotic change, and sequestra of varying size, from that of a nut to that of an infant’s head or larger, are formed. The earliest stage of this necrosis is usually infarction of the lung, a definite area of which becomes saturated with dark blood cells so that in contrast 609with the rest of even the hepatized lung, it is almost as characteristic as the marbling. ”

“ Observe the difference that there is between a gangrene of the soft parts, in which death takes place in a short time, with caries and necrosis of the bones, in which a long period elapses between disease and death of the part. In general we can say, when inflammation exists in a bone, that it is chronic. ”

“ The ulcers are not usually deep, but it may happen that they penetrate as far as the bone, and lead to necrosis. But usually necrosis of the bones is preceded by periostitis, and when the pus makes its way out, an ulceration leading down to necrotic bone is formed. ”

“ When necrosis is extensive, there is a risk of fracture occurring, if motion of the limb be permitted before a sufficient quantity of matter has been effused, before nature has had sufficient time for the consolidation of her substitute, and consequently before the new bone has come to resemble the old in thickness and cohesion. ”

“ Sloughing. Inflammation may be accompanied by sloughing or death of tissues. Gangrene, mortification or [Pg 34] necrosis is a death of the tissue from any cause. The part which has died is designated as a slough.
When inflammation has subsided, granulation tissue forms on the living tissue, exerting pressure upon the slough, thus hastening its absorption or separation.
Chronic Inflammation. An interruption at some stage of resolution or suppuration and the continuance of mild symptoms constitutes a chronic state. ”

“ Partial or local death may be molecular as in ulceration, or it may affect an organ or part of an organ, as in necrosis, sphacelus, or sloughing. Somatic death is a loss of vitality of the entire body and is manifested by a complete cessation of the bodily functions, including that of nutrition. Usually the arrest begins with one of the great vital processes, in advance of the others, and thus in different cases, we have death beginning at the heart, at the lungs, and at the brain. ”

“ Necrosis of the tissues is likely to set in: the flesh corrupts, falls from the bone sometimes in tatters; and the colors of its putrefaction simuulate the hues of vegetable decay,—the ghastly grays and pinks and yellows of trunks rotting down into the dark soil which gave them birth. ”

“ In a few cases the enormous irritation of the cerebral growth suddenly or gradually inhibits the heart's action through the impression made on the pneumogastric. Apoplectic attacks which may or may not terminate fatally sometimes are the result of a sudden giving way of necrosed brain-tissue, the necrosis having resulted from the obliteration of numerous blood-vessels by the advancing growth. Blood-poisoning occasionally takes place from abscesses in proximity to the tumor. ”

“ Perforating ulcers of the feet and gangrene about the toes bear evidence to a poorness of local nutrition, and a low vital tone of some of the tissues, also shown by the fact that necrosis of bone is a much more frequent sequela to blows than with hardier nations. ”

“ In death caused by hanging or strangling there may be fracture of the hyoid bone, thyroid cartilage or tracheal rings, marks upon the skin, hæmorrhage, laceration of the intima of the arteries, fracture or dislocation of the cervical vertebræ and injury to the cord. In death from drowning the bronchi, lungs and stomach may contain fluid, there is watery fluid in the pleural cavities, maceration of skin, greater water-content in blood of right heart than of left, with consequent raising of freezing point. ”

“ Wounds made during life might show the suggillation peculiar to bruises or traces of inflammation. Besides, the gaping nature of the lips of the wound, the fact of hemorrhage [431] having taken place and the coagulation of the blood, the infiltration of blood into the cellular tissue, etc., are surgical facts that would leave but little doubt as to the infliction of the wounds during life.
The cause of death is often a difficult matter to determine, as it may have been accidental, suicidal, or the result of homicide. ”

“ A Simple Wound is that which only opens the Flesh, and hath no other concomitant Circumstances; but a Complicated Wound, on the contrary, is that which is attended with grievous Symptoms, as Hæmorrhages, Fractures of Bones, Dislocation, Lameness, and others of the like Nature.
What is a dangerous and mortal Wound?
A dangerous Wound is that which is complicated the Accidents whereof are dreadful: As when an Artery is open'd or prick'd, when a Nerve or Tendon is cut, or when the Wound is near a Joynt and accompanied with a Dislocation or Fracture. ”

“ Some apply a tube about the barbs, so that when they draw out the weapon the flesh may not be torn by the barbs. If the wound does not become inflamed, we may use sutures, and heal it up like a bloody wound; but if it inflame we may remove the inflammation by embrocations, cataplasms, and the like. If the weapon be poisoned we must, if possible, cut off all the flesh which has imbibed the poison, which is known by its being altered from the sound flesh, for it appears pale, livid, and as it were dead. ”

“ The most dangerous wounds are those which implicate the large veins (blood-vessels) , in the neck and groin; then those of the brain and liver; next, those of the bowels and bladder. These cases are all dangerous, but not uniformly fatal, as some suppose. Much depends upon constitution, as to liability to fever and inflammation after a wound. Sometimes, also, the wounds of smaller vessels prove fatal by inducing hemorrhage, fever, or delirium. In all recent wounds, however, the physician should endeavor to afford assistance. ”

“ In hemorrhages she produces a faintness, which occasions a coagulum in the open vessels; so that the further passage of blood through them is obstructed.
[37]
In wounds of the flesh and bones she discharges foreign matter by exciting an inflammation, and supplies the waste of both with new flesh and bone.
II. There are cases where the efforts of nature are too feeble to do service, as in malignant and chronic fevers.
III. There are cases where the efforts of nature are over proportioned to the strength of the disease, as in the cholera morbus and dysentery. ”

“ Taylor [632] found among a large number of cases occurring in England during twenty years that the latent causes of death, as registered in wounded persons, were chiefly inflammation of the thoracic or abdominal viscera, apoplexy, diseases of the heart and large blood-vessels, phthisis, ruptures of the stomach and bowels from disease, internal strangulation, and the rupture of deep-seated abscesses. Sometimes the person was in good health up to the time of injury, while in other cases there was merely a slight indisposition. ”

“ It is necessary to examine what Part may be hurt, by considering the situation of the Wound, and its Symptoms: If the Lungs are pierc'd, a spitting of froathy Vermilion-colour'd Blood ensues, with difficulty of Respiration, and a Cough. If any of the great Vessels are open'd, the wounded Person feels a Weight at the bottom of his Breast, is seiz'd with cold Sweats, being scarce able to fetch his Breath, and Vomits Blood, some Portion whereof issueth out of the Wound. ”

“ Here a close attention to symptoms and a careful post-mortem examination can alone decide. A man may die from the rupture of an aneurism, from an apoplexy or some other morbid condition after receiving a severe wound. Or a man with a hernia may receive a blow upon it causing a rupture of the contained intestine followed by peritonitis and death, or the recipient of a blow may have a calculus in the kidney which may perforate a blood-vessel or the kidney tissue and set up a fatal hemorrhage as the result of a blow. ”

“ If required to make a post-mortem examination, every cavity and important organ of the body must be carefully and minutely examined, the seat of injury being inspected first.
V.—MODES OF SUDDEN DEATH
There are three modes in which death may occur: (1) Syncope; (2) asphyxia; (3) coma.
1. Syncope is death beginning at the heart—in other words, failure of circulation. It may arise from— (1) Anæmia, or deficiency of blood due to hæmorrhage, such as occurs in injuries, or from bleeding from the lungs, stomach, uterus, or other internal organs. ”

“ Among the secondary causes of death may be mentioned septicæmia, pyæmia, erysipelas, tetanus, gangrene, that is, wound diseases, also the wound accident—as we may call delirium tremens, and surgical operations rendered necessary to the treatment of the case. ”

“ When I touched the glands in the groin, they felt like walnuts under the skin, and it is, as I said, the presence of this obvious symptom which gives the plague its characteristic name of “bubonic,” from the Greek word for groin. After incision, the patient’s temperature often goes down rapidly, but, in any case, the pain from the glands is usually very great; indeed, I think it is the chief cause of such pain as the plague gives.
Next to heart failure, the commonest cause of death is lung complication after the crisis of fever is passed. ”

“ Consequently, with the exception of wounds inflicted very soon after death, we can distinguish an ante-mortem from a post-mortem wound by the condition in which the blood is clotted. If there is any hemorrhage, the wound being inflicted before the loss of animal heat and the blood remains entirely fluid on the surface or in an ecchymosis, we know that the wound was produced after death and some hours after death unless any of those conditions exist in which the blood does not normally coagulate. ”

“ Hemorrhage was prevented by pressure, by the binding on of burnt wool firmly, and by the ligature of veins and by the cautery.
There are rather interesting discussions of the [Pg 242] prognosis of wounds of the head, especially such as may be determined from general symptoms in this commentary of the Four Masters on Roger's and Rolando's treatises. If an acute febrile condition develops, the wound is mortal. If the patient loses the use of the hands and feet or if he loses his power of direction, or his sensation, the wound is mortal. If a universal paralysis comes on, the wound is mortal. ”